What is the recommended treatment for Hepatitis C (Hepatitis C virus) in a primary care setting?

Hepatitis C Treatment in the Primary Care Setting

The recommended first-line treatment for chronic hepatitis C in primary care is a pangenotypic direct-acting antiviral (DAA) regimen consisting of either sofosbuvir/velpatasvir for 12 weeks or glecaprevir/pibrentasvir for 8-12 weeks, depending on cirrhosis status and treatment history. 1, 2, 3

Recommended Treatment Regimens

For Treatment-Naïve Patients:

• Without cirrhosis:

  • Glecaprevir/pibrentasvir for 8 weeks 4, 1, 2
  • Sofosbuvir/velpatasvir for 12 weeks 4, 1, 2

• With compensated (Child-Pugh A) cirrhosis:

  • Glecaprevir/pibrentasvir for 8 weeks 4, 5
  • Sofosbuvir/velpatasvir for 12 weeks 4, 2

For Treatment-Experienced Patients:

• Without cirrhosis:

  • Glecaprevir/pibrentasvir for 8-16 weeks (depending on genotype and previous treatment) 4, 2
  • Sofosbuvir/velpatasvir for 12 weeks 4, 2

• With compensated (Child-Pugh A) cirrhosis:

  • Glecaprevir/pibrentasvir for 12-16 weeks (depending on genotype and previous treatment) 4, 2
  • Sofosbuvir/velpatasvir for 12 weeks (may require ribavirin for genotype 3) 4, 2

Simplified Treatment Approach for Primary Care

In primary care settings where genotype testing may be limited or unavailable, a simplified treatment approach is recommended:

• Pre-treatment assessment: 4

  • Confirm HCV infection (HCV RNA or HCV core antigen)
  • Assess for cirrhosis using non-invasive methods (FIB-4, APRI, or FibroScan)
  • Check for potential drug-drug interactions

• Treatment regimen (without genotype testing): 4

  • Non-cirrhotic patients: Glecaprevir/pibrentasvir for 8 weeks or sofosbuvir/velpatasvir for 12 weeks
  • Compensated cirrhosis: Glecaprevir/pibrentasvir for 12 weeks or sofosbuvir/velpatasvir for 12 weeks

Special Populations

Decompensated Cirrhosis (Child-Pugh B or C):

• Sofosbuvir/velpatasvir with ribavirin for 12 weeks 4, 2
• Important: Protease inhibitors (including glecaprevir) are contraindicated in decompensated cirrhosis 4, 5

Severe Renal Impairment:

• Glecaprevir/pibrentasvir is preferred for patients with severe renal impairment (eGFR <30 ml/min/1.73 m²) 2, 5
• Sofosbuvir-based regimens should be used with caution in severe renal impairment 2

HIV Co-infection:

• Same HCV treatment regimens as in HCV mono-infection 1, 2, 3
• Carefully assess for drug-drug interactions with antiretroviral therapy 3

Monitoring and Follow-up

• Pre-treatment:

  • Test all patients for HBV co-infection (HBsAg and anti-HBc) 4, 5
  • Assess for potential drug-drug interactions 4, 2

• During treatment:

  • Routine on-treatment viral load monitoring is no longer required due to high efficacy of current DAA regimens 2
  • Monitor for adverse effects: headache, fatigue, diarrhea, and nausea are most common 6

• Post-treatment:

  • Assess for sustained virologic response (SVR) at 12 weeks post-treatment 2
  • For patients with cirrhosis, continue monitoring for hepatocellular carcinoma with ultrasound every 6 months, even after achieving SVR 1, 2

Common Pitfalls and Caveats

• Risk of HBV reactivation: Test all patients for HBV before starting HCV treatment; monitor HBV/HCV co-infected patients for HBV reactivation during and after HCV treatment 5

• Drug-drug interactions: Carefully evaluate potential interactions before initiating DAA therapy, particularly with commonly prescribed medications in primary care 2, 3

• Patients with decompensated cirrhosis: Should be referred to specialists; protease inhibitors (glecaprevir) are contraindicated in these patients 4, 5

• Treatment failure: For patients who fail initial DAA therapy, sofosbuvir/velpatasvir/voxilaprevir for 12 weeks is recommended as rescue therapy 6

• Resistance testing: Generally not required before initial treatment but may be considered for genotype 3 patients with cirrhosis to detect NS5A Y93H resistance-associated substitution 4

The high efficacy (>95% SVR) and excellent safety profile of current DAA regimens have transformed HCV treatment, making it highly suitable for management in primary care settings 7, 8, 9.